Notes
Definition
It is a collection of fluid in the pleural space of the lungs. Fluid normally resides in the pleural space and acts as a lubricant for the pleural membranes to slide across one another when we breathe. Fluid is constantly being added and reabsorbed by capillaries and lymph vessels in the pleura. When this recycling process is interrupted, a pleural effusion can result.
Causes
Physicians determine the cause of the effusion based on the type of fluid that is accumulating.
- Transudative (watery fluid) effusions: Heart failure, pulmonary embolism, cirrhosis, post open heart surgery, trauma
- Exudative (protein-rich fluid) effusions: Pneumonia , cancers, pulmonary embolism, kidney disease, inflammatory diseases
Pleural fluid may be bloody (hemorrhagic), chylous (thick and white), rich in cholesterol, or purulent.
Signs and symptoms
(Small effusions may not present with symptoms and may only be found via chest X-ray. Larger effusions can cause symptoms such as:)
- Decreased lung expansion
- Dyspnea
- Dry, non-productive cough
- Tactile fremitus
- Orthopnea
- Tachycardia
Diagnostic Procedures
- Chest x-ray
- CT scan of the chest
- Ultrasound of the chest
- Thoracentesis
- Pleural fluid analysis via thoracentesis
Medical Management
- Thoracentesis
- Pleurectomy- consists of surgically stripping the parietal pleura from the visceral pleura. This produces and inflammatory reaction that causes adhesion formation between the two layers as they heal.
- Pleurodesis- involves the instillation of a sclerosing agent (talc, doxycycline, or tetracycline) into the pleural space via a thoracotomy tube. These agents cause the pleura to sclerose together.
Nursing interventions for pleural effusions
- Identify and treat the underlying cause
- Monitor breath sounds
- Place the client in a high Fowler’s position
- Encourage coughing and deep breathing
- Prepare the client for thoracentesis
- If pleural effusion is recurrent, prepare the client for pleurectomy or pleurodesis as prescribed
References
- Black, Joyce M. and Hawks, Jane H. Medical-Surgical Nursing. Clinical Management for Positive Outcomes. Pp 1872-1873
- http://my.clevelandclinic.org/disorders/pleural_effusion/ts_overview.aspx
- Silvestri, Linda Ann. Comprehensive Review for the NCLEX-RN Examination. 4th Ed. Pp 811-826
Nursing Care Plan
Nursing Diagnosis
- Ineffective Breathing Pattern RT Decreased Lung Volume Capacity as evidenced by tachypnea, presence of crackles on both lung fields and dyspnea
Planning
- Patient will demonstrate appropriate coping behaviors and methods to improve breathing pattern.
- Patient would be able to apply techniques that would improve breathing pattern and be free from signs and symptoms of respiratory distress.
Nursing Interventions
- Monitor and record vital signs.
- Rationale: To obtain baseline data
- Assess breath sounds, respiratory rate, depth and rhythm
- Rationale: To note for respiratory abnormalities that may indicate early respiratory compromise and hypoxia.
- Elevate head of the patient
- Rationale: To promote lung expansion
- Encourage patient to perform deep breathing exercises
- Rationale: To promote lung expansion.
- Provide relaxing environment
- Rationale: To promote adequate rest periods to limit fatigue
- Administer supplemental oxygen as ordered
- Rationale: To maximize oxygen available for cellular uptake
- Assist client in the use of relaxation technique
- Rationale: To provide relief of causative factors
- Administer prescribed medications as ordered
- Rationale: For the pharmacological management of the patient’s condition
- Maximize respiratory effort with good posture and effective use if accessory muscles.
- Rationale: To promote wellness
- Encourage adequate rest periods between activities
- Rationale: To limit fatigue
Assist and prepare for thoracentesis:
- Explain thoracentesis to the pain. Tell the patient to expect a stinging sensation from the local anesthetic and feeling of pressure when the needle inserted.
- Rationale: Knowing what to expect before the procedure can make the patient more apt to it.
- Instruct patient to tell him to tell you immediately if he feels uncomfortable or has difficulty of breathing during procedure.
- Rationale: If DOB occurs, it may require postponement of procedure.
- Reassure the patient during thoracentesis. Remind to breath normally and avoid sudden movements (coughing, sighing).
- Rationale: Reassure can relieve the anxiety that may occur during procedure.
- Monitor vital signs during procedure. Watch out for signs of respiratory distress after thoracentesis.
- Rationale: If fluid is removed too quickly, the patient may suffer bradycardia, hypotension, pain, pulmonary edema or even cardiac arrest.
- Ensure tube patency by watching for fluctuations of fluid or air bubbling in the underwater seal chamber. Record the amount, color, and consistency of any tube drainage.
- Rationale: Continuous bubbling may indicate an air leak.
Nursing Diagnosis
- Impaired Gas Exchange R/T Alveolar –Capillary Membrane Changes and respiratory fatigue Secondary to Pleural Effusion
Planning
Patient will demonstrate improved ventilation and adequate oxygenation of tissues AEB absence of symptoms of respiratory distress.
Nursing Interventions
- Monitor and record vital signs
- Rationale: To obtain baseline data
- Monitor respiratory rate, depth and rhythm
- Rationale: To assess for rapid or shallow respiration that occur because of hypoxemia and stress
- Assess pt’s general condition
- Rationale: To note for etiology precipitating factors that can lead to impaired gas exchange
- Auscultate breath sounds, note areas of decreased/adventitious breath sounds as well as fremitus
- Rationale: To evaluate degree of compromise
- Elevate head of the pt.
- Rationale: To enhance lung expansion
- Note for presence of cyanosis
- Rationale: To assess inadequate systemic oxygenation or hypoxemia
- Encourage frequent position changes and deep-breathing exercises
- Rationale: To promote optimum chest expansion
- Provide supplemental oxygen at lowest concentration indicated by laboratory results and client symptoms/ situation
- Rationale: To correct/ improve existing deficiencies
- Review laboratory results
- Rationale: To determine pt’s oxygenation status
- Provide health teaching on how to alleviate pt’s condition
- Rationale: To empower SO and pt
- Administer prescribed medications as ordered
- Rationale: For the pharmacological management of the patient’s condition
Nursing Diagnosis
- Activity Intolerance
Planning
- Patient will use identified techniques to improve activity intolerance
- Patient will report measurable increase in activity intolerance.
Nursing Interventions
- Establish Rapport
- Rationale: To gain clients participation and cooperation in the nurse patient interaction
- Monitor and record Vital Signs
- Rationale: To obtain baseline data
- Assess patient’s general condition
- Rationale: To note for any abnormalities and deformities present within the body
- Adjust client’s daily activities and reduce intensity of level.
- Rationale: To prevent strain and overexertion
- Discontinue activities that cause undesired psychological changes
- Rationale: To conserve energy and promote safety
- Instruct client in unfamiliar activities and in alternate ways of conserve energy
- Rationale: To relax the body
- Encourage patient to have adequate bed rest and sleep
- Rationale: To provide relaxation
- Provide the patient with a calm and quiet environment
- Rationale: To prevent risk for falls that could lead to injury
- Assist the client in ambulation
- Rationale: Fatigue affects both the client’s actual and perceived ability to participate in activities
- Note presence of factors that could contribute to fatigue
- Rationale: To determine current status and needs associated with participation in needed or desired activities
- Ascertain client’s ability to stand and move about and degree of assistance needed or use of equipment
- Rationale: To sustain motivation of client
- Give client information that provides evidence of daily or weekly progress
- Rationale: To enhance sense of well being
- Encourage the client to maintain a positive attitude
- Rationale: To promote easy breathing
- Assist the client in a semi-fowlers position
- Rationale: To maintain an open airway
- Elevate the head of the bed
- Rationale: To prevent injuries
- Assist the client in learning and demonstrating appropriate safety measures
- Rationale: To avoid risk for falls
- Instruct the SO not to leave the client unattended
- Rationale: To help minimize frustration and rechannel energy
- Provide client with a positive atmosphere
- Rationale: To indicate need to alter activity level
Nursing Diagnosis
- Acute Pain
Planning
- Patient will report pain is decreased or controlled.
Nursing Interventions
- Assess patient pain for intensity using a pain rating scale, for location and for precipitating factors.
- Rationale: To identify intensity, precipitating factors and location to assist in accurate diagnosis.
- Assess the response to medications every 5 minutes
- Rationale: Assessing response determines effectiveness of medication and whether further interventions are required.
- Provide comfort measures.
- Rationale: To provide nonpharmacological pain management.
- Establish a quiet environment.
- Rationale: A quiet environment reduces the energy demands on the patient.
- Elevate head of bed.
- Rationale: Elevation improves chest expansion and oxygenation.
- Monitor vital signs, especially pulse and blood pressure, every 5 minutes until pain subsides.
- Rationale: Tachycardia and elevated blood pressure usually occur with angina and reflect compensatory mechanisms secondary to sympathetic nervous system stimulation.
- Teach patient relaxation techniques and how to use them to reduce stress.
- Rationale: Anginal pain is often precipitated by emotional stress that can be relieved non-pharmacological measures such as relaxation.
